Opioid use disorder

Opioid use disorder

Anesthetic relevance	High
Anesthetic management	Use non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonist opioid analgesics (e.g. fentanyl, hydromorphone)
Specialty	Pain
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Diagnosis	{{{diagnosis}}}
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This article focuses primarily on management considerations for patients on Suboxone therapy.

Anesthetic implications

Patient's with opioid use disorder on maintenance therapy with Suboxone (buprenorphine-naloxone) or methadone are at high risk of inadequately controlled pain post-procedure due to low dosing or slow titration.

Pathophysiology

Buprenorphine is a partial mu-opioid receptor agonist and kappa-opioid receptor. It is unique in that its action at the mu-opioid receptor can block binding of other opioids.

Anesthetic management

Preoperative optimization

Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy. The dose of methadone or buprenorphine has implications for the risk of opioid tolerance and increased post-operative pain. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery . At doses lower than 8 mg/day, buprenorphine can be continued through procedure day and day of discharge. Similarly, it is recommended that patients on methadone continue their home dosing peri-operatively [1].

Non-opioid agents such as Tylenol and gabapentin/pregabalin. A shared neuro-inflammatory and central sensitization process akin to that of neuropathic pain may explain the cross-benefit of gabapentin in patients with opioid-induced hyperalgesia .

Intraoperative management

Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) are should be strongly considered in a non-opioid driven anesthetic. Ketamine is a useful adjunct due to it's useful effect of increasing opioid sensitivity when run at low dose rates (0.3 mg/kg/hr). Providers should consider Toradol and redosing of Tylenol in longer procedures.

Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression seen older patients, those with OSA, and patients with end-organ failure.

Postoperative management

Consider continuing methadone and buprenorphine as part of the post-operative pain management plan. Buprenorphine is unlikely to cause respiratory depression and causes less drug euphoria. Naloxone should not be co-administered due to the risk of causing acute withdrawal.

Providers should continue typical regimens for mild-severe pain post-op (oxycodone, fentanyl, hydromorphone), however higher than normal starting doses of opioids may be required. The typical calculation of milligram morphine equivalents (MME) do not give an accurate sense of equivalent dosing.

Consider post-operative stay in the ICU for pain management and consultation of in-house pain service.